GENDER DIVERSITY AND AUTISM:
LITERATURE REVIEW OF TRANSGENDER / NON-BINARY AND AUTISM RESEARCH
by Lisa Macafee
OVERVIEW OF THE STUDY
This is a systematic literature review on the relationship of autism and gender diversity, specifically, looking into any heightened gender ambivalence autism produces and correlations in gender diversity, intersex identities, and queer sexualities. Living in the intersecting identities of autistic and queer / transgender results in stigma and marginalization to the individual that may be exacerbated by stigmatizing treatment from mental and physical health care providers who may not well understand the needs of this population (Hall et al., 2020). This cultural competence gap is perpetuated in part by neglecting to include the voices of transgender autistic people in research so causality may be assumed about transgender autistic people by neurotypical cisgender researchers who themselves may not understand their research subjects (Strang et al., 2019). This literature review includes an analysis of previous research looking at autistic people and their understanding and relationships with their gender identity, sex, and sexuality to bring forward perspectives as to causality of the correlation between autism and gender non-conformity and/or queerness (Creswell, 2018). The focus of this literature review is on gender non-conformity in autistic individuals assigned female at birth (AFAB) (Walsh et al., 2018). Autistic women and autistic transgender people are such a small percentage of the population, their intricacies and needs in treatment often go ignored or are lumped in with other similar populations and will benefit from focused attention.
Background of the Problem
Heightened autistic traits have been found among individuals seeking gender related treatment (up to 35%) and among those who identify as transgender or non-binary (up to 15%) (Kung, 2020; Nobili et al., 2018; Walsh et al., 2018). Of the adult transgender population, 14% are diagnosed as autistic as compared to 0.62% of the general population and 94% of transgender autistics identify as non-binary (Walsh et al., 2018). Walsh et al. (2018) posit autistic individuals reject social conditioning to subscribe to a binary socially imposed gender system when compared to neurotypical peers who may subscribe more to the gender schema and may be more likely to suppress gender incongruence to conform. In one study, 15% of autistic people self-reported a transgender or non-binary identity, with AFAB participants reporting transgender identities 21.6% of the time compared to those assigned male at birth (AMAB) reporting transgender identities 7.8% (Walsh et al., 2018). Highest rates of autistic traits were found among transgender individuals AFAB (45% as compared to 30% for transgender AMAB) (Nobili et al., 2018).
Autistic individuals who identify as transgender, non-binary, or gender non-conforming typically experience increased stressors produced from their intersecting identities, primarily difficulties communicating needs around their gender and challenges navigating the complexities of gender expression and identity (Strang et al., 2018). Research on autism and gender diversity done without the voices of those autistic gender-diverse individuals poses problems in data analysis if information is misunderstood or misconstrued (Strang et al., 2019). Attempts to explain the correlation between autism and gender divergence can be harmful to the population if inaccurate or further marginalizing ideas are proposed, for example, some researchers assert autistic transgender individuals may be so only due to sensory difficulties making wearing dresses more preferable for AMAB autistics, which negates their agency and identity as transgender women, attributing their gender identity purely to sensory issues (Maroney & Horne, 2022). It is important to include the voices of those being studied in the research being done for accurate conclusions to be made (Strang et al., 2019).
Health care providers have been seeing a higher prevalence of autistic traits among individuals seeking gender affirming care: 14% of those seeking gender affirming care were diagnosed autistic compared to an adult average of 0.62% (Walsh et al., 2018). Autistic individuals are more likely to be transgender for many reasons, one of which being an inherent resistance to social conditioning and expected gender roles allowing for autistic individuals to disregard the binary gender system and reputation management in which many feel the need to comply (Walsh et al., 2018). The most significant correlation of autism and gender was between AFAB autistics identifying as non-binary; only 6% of transgender autistics identified as binary men or women; it seems to be autistic individuals, especially AFAB, are more open to examining their gender identity, less likely to feel pressure to conform to gender norms, and 15% identify as non-binary / transgender compared to 3.9% of the general population (Walsh et al., 2018).
There are also elevated autistic traits in transgender people, especially those AFAB, of which; 45% of AFAB transgender people have significantly higher autistic traits than the general population as measured by the Autism Quotient (AQ) as compared to 30% of transgender people AMAB (Nobili et al., 2018). Some research posits transgender people might score higher on the AQ because they often experience more social, health, psychological isolation, pervasive anxiety, and low self-esteem (Nobili et al., 2018). Nobili et al. (2018) posed an “extreme male brain theory” of autism which states, autistic individuals may have been exposed to heightened levels of testosterone in utero causing a drive to systematize, to explain why autism occurs more in men than women (4:1 ratio) and why many AFAB autistics are transgender. Another study showed 15% of transgender men and 19% of AFAB non-binary people meeting autism cut-offs rates while those AMAB did not meet significant cut-offs for autism leading researchers to theorize autistics may have more of a testosterone-influenced brain influencing those AFAB to present more masculine (Kung, 2020).
Autism is more common among transgender individuals; about 15% of autistic individuals identify as transgender, non-binary, or gender non-conforming, much higher than the general transgender rates in the population (Maroney & Horne, 2022). Autistic transgender people experience intersectional stigmas of ableism and cissexism including barriers to accessing health care, discrimination, and access challenges (Maroney & Horne, 2022); 58.2% of therapists said they know about examples of bias in treatment from their peers towards the queer community, only 34% of psychology graduates reported diversity education as part of their training, and LGBTQ+ clients have reported perceptions of heterosexism from therapists and dissatisfaction with their treatment (Carroll & Gilroy, 2001). Autistic people AFAB are 1.68 times more likely to be transgender, 2.39 times more likely to be gay, and 2.33 times more likely to be bisexual when compared to non-autistic women (Pecora, 2020). Autistic gay women reported experiencing regrettable sexual experiences 2.72 times as often and unwanted sexual behaviors 3.17 times as often as autistic heterosexual women while autistic women overall experienced unwanted sexual experiences 2.98 times more than non-autistic women (Pecora, 2020). It is important for mental and physical health care practitioners to have accurate information on marginalized populations to be able to best support them. It is estimated autistic AFAB people have these higher rates of adverse sexual experiences partially due to the higher rates of sexual victimization among gender diverse populations, as transgender women reported regrettable sexual experiences 4.01 times more often than cisgender women, and other causes of aversive experiences are linked to autistic people’s lessened ability to perceive red flags due to social impairment in relationships or communicate needs as well as non-autistic people (Pecora, 2020). Add to this the additional struggle women are often missed in diagnosis for autism, it is estimated the true ratio of autism in men to women is 3:1 and not 4:1 as the rate diagnosed because many diagnosing practitioners are not adept at diagnosing women; (Zener, 2019). Autistic women diagnosed after age 18 are more likely to be diagnosed with PTSD (up to 17% of autistic women) due to trauma exposure, depression, and misdiagnosis, more have eating disorders (up to 30% of women with anorexia qualify for an autism diagnosis), and many struggle with diagnosis of borderline personality disorder, obsessive compulsive disorder, burnout, or failure to launch challenges (Zener, 2019).
For many neurodivergent people, their identities are already seen as “queer” by mainstream society, as disability has been pathologized by medicine and religion as other and less than, which have systemic impacts on the transgender autistic community (Abrams & Abes, 2021). According to Hall et al. (2020), LGBTQ+ autistic people experience more than double the rates of mental health concerns (78.9% versus 34.3%) and days of bad physical health per month (11.1 versus 5.1). They smoked almost ten times more (26.3% versus 2.9%), had higher unmet health care needs (73.7% versus 43.8%), and had been refused health care more (35.7% versus 20%) when compared to their cisgender/straight autistic peers (Hall et al., 2020). Transgender people experience heightened levels of mental health problems, notably in anxiety, depression, and self-harm; higher levels of autistic traits among transgender people may be due to chronic stress manifesting as autistic traits (Nobili et al., 2018). Autistic gender diverse individuals are especially likely to struggle with finding and receiving appropriate health care, navigating relationships, and assess safety concerns while also trying to create affirming community due to stigma and negative experiences experienced causing hesitancy to self-advocate (Maroney & Horne, 2022).
The problem being investigated is the lack of cultural competence among mental health care providers for queer autistic people causing missed or misdiagnosis and results in inappropriate treatment causing harm to gender diverse autistic people (Hall et al., 2020). The DSM-V defines autism strictly as the absence of neurotypicality instead of neutral statements of what is autism (Maroney & Horne, 2022). Health disparities exist for autistic individuals who are also LGBTQ+ (Hall et al., 2020). Misunderstanding populations or misattributing traits to them they do not identify with can cause populations harm, with decreased mental and physical health outcomes, and yet, few voices of autistic people are involved in research to help explain these concerns (Strang et al., 2019). It is important accurate and recent research is used to determine best practices, including voices from autistic gender diverse people themselves to explain the issues as they see them, to prevent assumptions of causality based on neurotypical perspectives contributing to the existing mental health disparities (Maroney & Horne, 2022).
Purpose of the Study
The purpose of this systematic literature review is to provide a cohesive body of knowledge summarizing recent research on transgender/non-binary and autistic treatment, correlations, and issues. This literature review includes analysis of recent research to identify how transgender and non-binary autistic people perceive gender and sexuality, how they see gender and sexuality relating to autistic traits they have, and treatment recommendations and best practices. This review includes summaries of research in a comprehensive, culturally sensitive, and inclusive manner. Research studies will be examined from ProQuest, EBSCOHost, Google Scholar, and PsychiatryToday databases, along with some excerpts from books and grey articles.
RQ1. What does research data demonstrate as to the relationship between autistic adults (especially those AFAB) and non-binary and transgender identities?
RQ2. How do autistic adults’ sex, gender, and gender identity differences develop?
RQ3. What mental health treatment methods and practices are recommended to best serve the transgender and non-binary autistic population?
Autism and gender identity will be analyzed through the theoretical lenses of queer theory and crip theory. These theories help frame the problem of autistic transgender people being ill-treated due to ignorance, bias, or lack of understanding in the research on autistic transgender people (Creswell, 2018). Queer theory is founded in questioning the norms of gender and sexuality enforced by society (Carroll & Gilroy, 2001). This is especially pertinent for queer autistic people as they may not intuit the roles others expect them to take and may have less ability to identify barriers due to sexuality or gender identity and how to address them due to their autistic nature. For many, sex, gender, and sexuality are performative acts based on the internalization of societal expectations and the individual’s situation and sexual orientation and gender identity change over time and are not pre-determined (Verma et al., 2023).
Queer theory resists normalizing and privileging certain identities over others and encourages society to resist policing other people’s expressions outside of the commonly accepted binary identities (Verma et al., 2023). People do not all fit conveniently into the gender binaries presented (male/female) and queer theory helps to break down some of the heteronormative structures and pressure to conform, question assumptions about gender and sexuality, focus on the systems of power that divide, and support people who identify as transgender or non-binary (Carroll & Gilroy, 2001). According to Jones (2021), transgender people are often given more privilege and power in society if they perform a cisgender role, but this may feel inauthentic to their true self and prevent them having genuine relationships for fear of being “found out”. Conversely, adopting a queer identity as a transgender person risks danger and abuse in the world; attaining a state of good mental health may be very difficult for some without the rejection of the binary and safe living situations (Jones, 2021). Queer theory posits by not adhering to gender binaries, queer and transgender people disrupt systems of power contributing to others living artificially or stigmatizing roles due to fear and allowing others to question their assumptions on gender and sexuality (Jones, 2021). Queer theory has been a political rallying cry to encourage individuals to think outside the hegemonic boxes society has construed as the only options and has encouraged people to create new ways of being that do not involve being stuck inside of binary socially prescribed attitudes and beliefs (Burns, 2021). It is important when individuals realize the roles they have internalized to perform become restrictive or harmful, they develop a cultural flexibility allowing them to leave paradigms not serving them behind to forge a better future for themselves (Kokkos, 2022). Queer theory emphasizes the importance of critically evaluating schemas purported to be “normal” (such as gender roles) to identify harmful elements perpetuated in order to keep certain populations in power and others minoritized (Kokkos, 2022).
Similarly, crip theory, created by Robert McRuer in the early 2000s, was made to deconstruct ideas about disability and being disabled and focuses on how reality can be re-shaped and re-imagined to allow for other ways of being to exist in the world and avoids use of the word “normal” in favor of modalities allowing individuals to, not just survive, but flourish, while existing outside of assimilation and typicality (Kafer, 2009). Crip theory rejects ableism (compulsory able-mindedness and able-bodiedness); ableism states bodies and minds more typical are therefore more valuable, and bodies and minds veering further from “normal” are therefore less deserving of space in the world; but disability is a naturally occurring variation in humans and all people are normal – although all people are not typical (Abrams & Abes, 2021). For people who are disabled and queer, assimilationist ideologies will never work to build authentic paradigms of power and privilege, because the individual will always be fundamentally different from what is expected as typical. Essentially, crip theory argues while queer disabled people are constantly being displaced by society, the brightest possibilities come about in the refusal of displacement (Kafer, 2009).
Just as the word queer encompasses a variety of identities under the LGBTQ+ umbrella, the word disability also encompasses spectrums of differences and society has seemingly deemed both groups inferior to the able-bodied, neurotypical, cisgender, heterosexual person, which causes people in marginalized identities challenges (Kafer, 2009). Autism is associated with higher rates of transgender identities and these two intersecting marginalized identities produce stigma to the individuals who live in this intersection and part of this marginalization is brought on by a biased and stigmatizing view of mental and physical health care providers who do not well understand the needs of this population (Hall et al., 2020). This is perpetuated in part by neglecting to include the voices of transgender autistic people in research and causality is often assumed about this population by neurotypical cisgender researchers who themselves may not understand this population (Strang et. al., 2019). This literature review includes an exploration of the correlation between autism and gender non-conformity utilizing queer theory and crip theory as frameworks for alternate ways people may exist and be empowered in the world and to guide the line of inquiry away from reinforcing societal norms to attempt an honest exploration of the issues at hand (Creswell, 2018).
Definitions and Key Terms
Assigned Female at Birth (AFAB)
Transgender people who were assigned female at birth (AFAB) are often referred to as AFAB to denote which gender they were assigned before or irrespective of transition, a transgender man was typically AFAB (Nobili et al., 2018).
Assigned Male at Birth (AMAB)
Transgender people who were assigned male at birth (AMAB) are often referred to as AMAB to denote which gender they were assigned before or irrespective of transition, a transgender woman was typically AMAB (Nobili et al., 2018).
Autism or Autistic
Autism is a fundamental difference in the way people interact and communicate that includes differences in thinking, socialization, sensory processing, and communication and at times, autism is referenced to under the umbrella term of neurodiversity, which includes other neuro-minorities (Maroney, Horne, 2022). Throughout this paper, both “individual with autism” and “autistic individual” are used interchangeably. As a note, the autism community generally prefers identity-first language (autistic person) while the disability rights community as a whole generally prefers person-first language (person with autism) (Carroll, 2019).
Cisgender described people whose gender identity matched what they were assigned at birth, for example a cisgender woman was assigned female at birth and identifies as female as an adult (Nobili et al., 2018).
To be intersex means an individual has had a natural diverse sexual development outside of the typical male/female binary in physical sex characteristics, hormones, or chromosomes (Roen, 2019).
Queer is an umbrella term including nonnormative sexualities such as gay, bisexual, and pansexual as well as nonnormative gender identities such as transgender, non-binary, and gender fluid, among many others; queer is a way to identify many minoritized groups under one identity (Burns, 2021).
Non-Binary / Transgender / Gender Diverse / Gender Non-Conforming
Transgender is used as an umbrella term in this paper and is used to describe anyone who do not identify 100% with the gender assigned to them at birth, including transgender binary identities (transgender men and transgender women), transgender non-binary identities such as (non-binary, agender), gender diverse identities (such as third gender, gender fluid, bi-gender), and gender non-conforming individuals (Strang et al., 2019).
Abrams, E. J., & Abes, E. S. (2021). "It's Finding Peace in My Body": Crip Theory to Understand Authenticity for a Queer, Disabled College Student. Journal of College Student Development, 62(3), 261-275. http://proxy1.calsouthern.edu/login?url=https://www-proquest-com.csu.idm.oclc.org/scholarly-journals/finding-peace-my-body-crip-theory-understand/docview/2547639324/se-2
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5. American Psychiatric Association Publishing.
Burns, R. (2021). Queerness as/and political attunement: a brief response to Anderson & Knee (2020) Queer Isolation or Queering Isolation? Leisure Sciences, 43(1/2), 125–130. https://doi-org.csu.idm.oclc.org/10.1080/01490400.2021.1874575
Carroll, L., & Gilroy, P. J. (2001). Teaching “Outside the Box”: Incorporating Queer Theory in Counselor Education. Journal of Humanistic Counseling, Education & Development, 40(1), 49–58. https://doi-org.csu.idm.oclc.org/10.1002/j.2164-490X.2001.tb00101.x
Carroll, S. (2019). Respecting and empowering vulnerable populations: Contemporary terminology. The Journal for Nurse Practitioners, 15(3), 228-231. https://doi-org.csu.idm.oclc.org/10.1016/j.nurpra.2018.12.031
Creswell, J. W. (2018). Research design: Qualitative, quantitative, and mixed methods approaches. (5th ed.). Sage.
Hall, J. P., Katie, B., Streed,Carl G.,,Jr, Boyd, B. A., & Kurth, N. K. (2020). Health disparities among sexual and gender minorities with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(8), 3071-3077. https://doi-org.csu.idm.oclc.org/10.1007/s10803-020-04399-2
Jones, D. B. (2021). De-colonizing my trans body: Fanon and the masks I have worn. Existential Analysis: Journal of the Society for Existential Analysis, 32(2), 322–332.
Kafer, A. (2009). What's Crip About Queer Theory Now?: Crip Theory: Cultural Signs of Queerness and Disability. By Robert McRuer, New York, New York University Press, 2006. 283 pp. $22.00 (paperback). ISBN-10: 0814757138. Sex Roles, 60(3-4), 291-294. https://doi-org.csu.idm.oclc.org/10.1007/s11199-008-9511-6
Kokkos, A. (2022). Transformation theory as a framework for understanding transformative learning. Adult Education – Critical Issues (2)2, 20-33. Retrieved from https://www.researchgate.net/publication/366826194_Transformation_Theory_as_a_Framework_for_Understanding_Transformative_Learning on May 31st 2023.
Kung, K. T. F. (2020). Autistic traits, systematizing, empathizing, and theory of mind in transgender and non-binary adults. Molecular Autism, 11, 1-8. https://doi-org.csu.idm.oclc.org/10.1186/s13229-020-00378-7
Maroney, M. R., & Horne, S. G. (2022). “Tuned into a different channel”: Autistic transgender adults’ experiences of intersectional stigma. Journal of Counseling Psychology, 69(6), 761–774. https://doi-org.csu.idm.oclc.org/10.1037/cou0000639.supp (Supplemental)
MasterClass. (2022). Queer Theory: Definition, history, and impact. Retrieved from https://www.masterclass.com/articles/queer-theory on May 31st, 2023.
Nobili, A., Glazebrook, C., Bouman, W. P., Glidden, D., Baron-Cohen, S., Allison, C., Smith, P., & Arcelus, J. (2018). Autistic Traits in Treatment-Seeking Transgender Adults. Journal of Autism & Developmental Disorders, 48(12), 3984–3994. https://doi-org.csu.idm.oclc.org/10.1007/s10803-018-3557-2
Pecora, L. A., Hancock, G. I., Hooley, M., Demmer, D. H., Attwood, T., Mesibov, G. B., & Stokes, M. A. (2020). Gender identity, sexual orientation and adverse sexual experiences in autistic females. Molecular Autism, 11, 1-16. https://doi-org.csu.idm.oclc.org/10.1186/s13229-020-00363-0
Roen, K. (2019). Intersex or Diverse Sex Development: Critical Review of Psychosocial Health Care Research and Indications for Practice. Journal of Sex Research, 56(4/5), 511–528. https://doi-org.csu.idm.oclc.org/10.1080/00224499.2019.1578331
Strang, J. F., Klomp, S. E., Caplan, R., Griffin, A. D., Anthony, L. G., Harris, M. C., Graham, E. K., Knauss, M., & van der Miesen, A. I. R. (2019). Community-based participatory design for research that impacts the lives of transgender and/or gender-diverse autistic and/or neurodiverse people. Clinical Practice in Pediatric Psychology, 7(4), 396–404. https://doi-org.csu.idm.oclc.org/10.1037/cpp0000310
Strang, J. F., Powers, M. D., Knauss, M., Sibarium, E., Leibowitz, S. F., Kenworthy, L., Sadikova, E., Wyss, S., Willing, L., Caplan, R., Pervez, N., Nowak, J., Gohari, D., Gomez-Lobo, V., Call, D., & Anthony, L. G. (2018). “They Thought It Was an Obsession”: Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents. Journal of Autism & Developmental Disorders, 48(12), 4039–4055. https://doi-org.csu.idm.oclc.org/10.1007/s10803-018-3723-6
Verma, T., Chapman-Orr, E., Davis, A. What is queer theory? Grinnell College: Subcultures and Society. Retrieved from https://haenfler.sites.grinnell.edu/subcultural-theory-and-theorists/queer-theory/ on May 31st, 2023.
Walsh, R. J., Krabbendam, L., Dewinter, J., & Begeer, S. (2018). Brief report: gender identity differences in autistic adults: associations with perceptual and socio-cognitive profiles. Journal of Autism & Developmental Disorders, 48(12), 4070–4078. https://doi-org.csu.idm.oclc.org/10.1007/s10803-018-3702-y
Zener, D. (2019). Journey to diagnosis for women with autism. Advances in Autism, 5(1), 2-13. https://doi-org.csu.idm.oclc.org/10.1108/AIA-10-2018-0041
Hello friends! I would like to publish writings from myself and other people with autism as snapshots of how autism has affected them, since there are so many misconceptions and confusions about adults with autism.
Some background: I completed a 12 unit certificate program to be able to serve autistic students and am angry at how the program focused only on little boys as autistic and completely left out adults, the trans autistic population, and girls/ femmes/ women autistics. I am currently pursuing a PsyD to do more research on autism and gender.
Please contact me if you would like to add a story! If so, please send me your piece, publish name, title, and an image (can be a picture related to your content, your picture, an autism meme, etc).
I am interested in publishing this collection, because people don't know enough about us (but sure do assume a lot). Also on Facebook!
Lisa Macafee, autistic counselor with a hankering for social justice.